Practical Approach to Management of Patients With Cancer During the COVID-19 Pandemic: An International Collaborative Group Statement

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In an article published in The Oncologist, an international collaborative group outlined issues and potential management approaches for the treatment of patients with cancer during the COVID-19 pandemic.

Key issues facing cancer treatment and some of the potential measures for addressing these issues identified by the collaborative group are summarized/reproduced below.

Resource Allocation

  • Strategies should be implemented to minimize interruption of cancer treatment, particularly in patients being treated with curative intent. However, to promote physical distancing and in anticipation of increased workload, it is recommended that elective surgeries and nonurgent outpatient clinics be deferred.
  • Effective communication and transparency among stakeholders, suppliers, and health organizations are critical for strategies for managing drug shortages.

Cancer Diagnosis

  • Diagnosis and timely treatment of patients should not be compromised; however, the management of patients should be tailored to the best available resources. The necessity of any interventional procedure must be balanced against the increased risk during the pandemic and should be evaluated on a case-by-case basis to address the urgency of the procedure and effect on patient outcome if the procedure is deferred.

Patients in Outpatient Settings

  • Outpatient visits should be reduced to the safest level without jeopardizing patient care. Measures to help reduce transmissions in outpatient settings include clear communication and education about hand hygiene, infection control measures, signs and symptoms of COVID-19 infection, and high-risk travel or exposure, and stressing the importance of reporting new symptoms to health-care workers. Clinic attendance should be limited to the patient and one visitor (or no visitors).
  • Ambulatory care clinics, including chemotherapy infusion units, must adhere to strict screening and be prepared to identify and transfer potential cases safely without risking disease transmission.
  • Clinics should create a simple screening algorithm or questionnaire for early detection of potentially infectious persons. Individuals who meet criteria for COVID-19 should be provided a mask and placed in a private exam room as soon as possible.
  • Chemotherapy infusion units should function at usual capacity to avoid cancer treatment delays. Switching patients on active outpatient anticancer therapy from intravenous to appropriate oral drugs can be considered on a case-by-case basis. For oral anticancer therapy in the outpatient setting, follow-up visits can be reduced to the safest minimum. Consideration of a chemotherapy break/holiday can be considered on a case-by-case basis.
  • Telemedicine should be considered to support patients to reduce in-person hospital visits; this may include providing a hospital hotline and expanded telehealth capabilities.
  • Radiation therapy patients need to attend treatment daily, since interruption of therapy is clinically unacceptable. Even if no new cases are started, patients currently on treatment must continue treatment. Patients who are at risk for COVID-19 who are a known contact should be seen and treated in a separate room.

Hospitalized Patients

  • The application of designated units with cohorting of COVID-19 patients is advisable, although the scale of the pandemic may preclude dedicated nursing for all infected patients. Nevertheless, when possible, it is advisable to dedicate health-care practitioners to the care of COVID-19 patients to reduce opportunities for transmission to uninfected patients.
  • Strict and safe triaging procedures are critical to assessing COVID-19 symptoms and the urgency and necessity of hospitalization at entry points, especially in emergency rooms. Restrictions on hospital-based ambulatory care, nonurgent hospital utilization, and hospital transfers may be a safe public health strategy.
  • Patients with suspected COVID-19 infection should be admitted first to an isolation room until testing is performed. Grouped areas with minimization of staff overlap with other patient care areas should ideally be available for confirmed COVID-19 cases. If COVID-19 infection is excluded, transfer to the appropriate service should be considered; however, patients should be evaluated for the need for quarantine if the patient has been exposed to a close contact of a confirmed case or has other epidemiologic risk. If the patient is positive for infection, COVID-19 isolation procedures should be instituted.
  • To minimize occupational exposure to the virus and reduce risk of nosocomial transmission, provision of adequate personal protective equipment (PPE) for health-care workers and rigorous application of infection prevention and control measures in health-care facilities is mandatory. While PPE kits should be made available, conservation efforts for all critical PPE should be implemented when there are resource constraints.

Oncology Health-Care Workers

  • Social distancing and separation of clinic workspaces are important to reduce risk of infection. If staff members are required to self-isolate due to contact with a confirmed case, measures that allow them to continue to provide care and/or support multidisciplinary tumor boards should be considered (eg, virtual attendance at multidisciplinary tumor board meetings; telephone or video consultations, especially follow-ups; making contact with vulnerable patients to discuss changes to care and treatment; and identifying patients suitable for remote monitoring/follow-up).

Active Anticancer Treatment for Patients Who Are Infected or Who Are at High Risk

  • Delaying curative adjuvant chemotherapy can be considered within the accepted duration for each disease site.
  • Patients will be classified as either having confirmed infection or at high risk for COVID-19. Those with confirmed COVID-19 infection should be assessed for holding anticancer therapy until they are deemed medically clear as per the clinical guidance available at the WHO and CDC websites:
  • Patients who are on active anticancer therapy continue to be at high risk of infection, and vigilance for COVID-19 symptoms must be maintained.

The collaborative group statement also features discussion of considerations regarding surgery in patients at risk of infection, special considerations for patients with lung cancer and hematopoietic cell transplant recipients, and the potential impact of the pandemic on cancer research and clinical trials. 

Humaid O. Al-Shamsi, MD, of the University of Sharjah, United Arab Emirates, is the corresponding author for The Oncologist article.

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